0:00:22.005,0:00:24.308
We all go to doctors.

0:00:26.299,0:00:30.227
And we do so with trust and blind faith

0:00:30.227,0:00:34.397
that the test they are ordering[br]and the medications they're prescribing

0:00:34.397,0:00:36.840
are based upon evidence --

0:00:37.403,0:00:40.306
evidence that's designed to help us.

0:00:41.560,0:00:47.285
However, the reality is that that hasn't[br]always been the case for everyone.

0:00:48.055,0:00:49.734
What if I told you

0:00:49.734,0:00:53.469
that the medical science discovered[br]over the past century

0:00:53.469,0:00:57.088
has been based on only[br]half the population?

0:00:59.171,0:01:01.580
I'm an emergency medicine doctor.

0:01:02.074,0:01:05.496
I was trained to be prepared[br]in a medical emergency.

0:01:06.043,0:01:09.670
It's about saving lives. How cool is that?

0:01:11.948,0:01:14.952
OK, there's a lot of runny noses[br]and stubbed toes,

0:01:14.952,0:01:17.871
but no matter who walks[br]through the door to the ER,

0:01:18.703,0:01:20.955
we order the same tests,

0:01:20.955,0:01:23.254
we prescribe the same medication,

0:01:23.254,0:01:26.936
without ever thinking about the sex[br]or gender of our patients.

0:01:28.610,0:01:30.211
Why would we?

0:01:30.211,0:01:33.884
We were never taught that there were[br]any differences between men and women.

0:01:36.612,0:01:41.289
A recent Government Accountability study[br]revealed that 80 percent of the drugs

0:01:41.289,0:01:42.958
withdrawn from the market

0:01:42.958,0:01:45.594
are due to side effects on women.

0:01:47.354,0:01:49.565
So let's think about that for a minute.

0:01:49.565,0:01:52.500
Why are we discovering[br]side effects on women

0:01:52.917,0:01:55.794
only after a drug has been[br]released to the market?

0:01:57.294,0:02:02.462
Do you know that it takes years[br]for a drug to go from an idea

0:02:03.147,0:02:05.665
to being tested on cells in a laboratory,

0:02:06.065,0:02:07.981
to animal studies,

0:02:08.111,0:02:10.435
to then clinical trials on humans,

0:02:10.435,0:02:14.141
finally to go through[br]a regulatory approval process,

0:02:14.141,0:02:18.149
to be available for your doctor[br]to prescribe to you?

0:02:20.200,0:02:23.547
Not to mention the millions and billions[br]of dollars of funding

0:02:23.547,0:02:25.807
it takes to go through that process.

0:02:27.537,0:02:30.498
So why are we discovering[br]unacceptable side effects

0:02:30.498,0:02:34.185
on half the population[br]after that has gone through?

0:02:37.153,0:02:38.847
What's happening?

0:02:39.006,0:02:41.839
Well, it turns out that those cells[br]used in that laboratory,

0:02:42.889,0:02:44.571
they're male cells,

0:02:44.890,0:02:48.205
and the animals used[br]in the animal studies were male animals,

0:02:48.205,0:02:52.474
and the clinical trials have been[br]performed almost exclusively on men.

0:02:54.970,0:02:59.720
How is it that the male model became[br]our framework for medical research?

0:03:03.024,0:03:06.808
Let's look at an example that has been[br]popularized in the media,

0:03:07.161,0:03:10.292
and it has to do[br]with the sleep aid Ambien.

0:03:10.593,0:03:14.268
Ambien was released on the market[br]over 20 years ago,

0:03:15.000,0:03:19.772
and since then, hundreds of millions[br]of prescriptions have been written,

0:03:19.772,0:03:24.157
primarily to women, because women[br]suffer more sleep disorders than men.

0:03:25.445,0:03:27.545
But just this past year,

0:03:27.545,0:03:31.384
the Food and Drug Administration[br]recommended cutting the dose in half

0:03:31.384,0:03:33.108
for women only,

0:03:34.046,0:03:36.980
because they just realized[br]that women metabolize the drug

0:03:36.980,0:03:38.961
at a slower rate than men,

0:03:39.634,0:03:41.924
causing them to wake up in the morning

0:03:41.924,0:03:44.855
with more of the active drug[br]in their system.

0:03:44.855,0:03:48.978
And then they're drowsy and they're[br]getting behind the wheel of the car,

0:03:48.978,0:03:51.546
and they're at risk[br]for motor vehicle accidents.

0:03:53.278,0:03:57.014
And I can't help but think,[br]as an emergency physician,

0:03:57.014,0:04:01.618
how many of my patients[br]that I've cared for over the years

0:04:02.249,0:04:04.831
were involved in a motor vehicle accident

0:04:04.831,0:04:08.017
that possibly could have been prevented

0:04:08.017,0:04:13.171
if this type of analysis was performed[br]and acted upon 20 years ago

0:04:13.711,0:04:16.096
when this drug was first released.

0:04:17.548,0:04:20.812
How many other things need[br]to be analyzed by gender?

0:04:21.523,0:04:23.530
What else are we missing?

0:04:27.579,0:04:30.694
World War II changed a lot of things,

0:04:31.586,0:04:34.535
and one of them was this need[br]to protect people

0:04:34.535,0:04:38.932
from becoming victims of medical research[br]without informed consent.

0:04:39.881,0:04:43.342
So some much-needed guidelines[br]or rules were set into place,

0:04:43.342,0:04:48.350
and part of that was this desire[br]to protect women of childbearing age

0:04:48.350,0:04:51.377
from entering into any[br]medical research studies.

0:04:52.557,0:04:56.898
There was fear: what if something[br]happened to the fetus during the study?

0:04:57.542,0:04:59.994
Who would be responsible?

0:04:59.994,0:05:03.115
And so the scientists[br]at this time actually thought

0:05:03.115,0:05:05.637
this was a blessing in disguise,

0:05:05.637,0:05:07.734
because let's face it --

0:05:10.339,0:05:12.713
men's bodies are pretty homogeneous.

0:05:12.999,0:05:16.730
They don't have the constantly[br]fluctuating levels of hormones

0:05:16.730,0:05:20.405
that could disrupt clean data[br]they could get if they had only men.

0:05:21.603,0:05:24.535
It was easier. It was cheaper.

0:05:25.893,0:05:28.927
Not to mention, at this time,[br]there was a general assumption

0:05:28.927,0:05:32.193
that men and women[br]were alike in every way,

0:05:32.747,0:05:35.847
apart from their reproductive organs[br]and sex hormones.

0:05:37.563,0:05:39.826
So it was decided:

0:05:41.151,0:05:43.989
medical research was performed on men,

0:05:44.647,0:05:47.533
and the results were later[br]applied to women.

0:05:49.462,0:05:52.727
What did this do to the notion[br]of women's health?

0:05:52.727,0:05:56.922
Women's health became synonymous[br]with reproduction:

0:05:57.534,0:06:01.163
breasts, ovaries, uterus, pregnancy.

0:06:02.597,0:06:05.490
It's this term we now refer[br]to as "bikini medicine."

0:06:06.821,0:06:09.407
And this stayed this way[br]until about the 1980s,

0:06:09.407,0:06:12.632
when this concept was challenged[br]by the medical community

0:06:12.676,0:06:16.693
and by the public health policymakers[br]when they realized that

0:06:17.145,0:06:20.450
by excluding women[br]from all medical research studies

0:06:21.387,0:06:23.857
we actually did them a disservice,

0:06:24.746,0:06:27.068
in that apart from reproductive issues,

0:06:27.068,0:06:30.365
virtually nothing was known[br]about the unique needs

0:06:30.365,0:06:31.901
of the female patient.

0:06:33.221,0:06:38.221
Since that time, an overwhelming amount[br]of evidence has come to light

0:06:38.836,0:06:43.847
that shows us just how different[br]men and women are in every way.

0:06:49.459,0:06:52.205
You know, we have this saying in medicine:

0:06:52.205,0:06:55.047
children are not just little adults.

0:06:57.171,0:06:59.412
And we say that to remind ourselves

0:06:59.412,0:07:03.442
that children actually have[br]a different physiology than normal adults.

0:07:05.070,0:07:09.613
And it's because of this that the medical[br]specialty of pediatrics came to light.

0:07:10.035,0:07:15.784
And we now conduct research on children[br]in order to improve their lives.

0:07:17.407,0:07:20.301
And I know the same thing[br]can be said about women.

0:07:20.301,0:07:24.487
Women are not just men[br]with boobs and tubes.

0:07:26.981,0:07:30.178
But they have their own[br]anatomy and physiology

0:07:30.178,0:07:33.126
that deserves to be studied[br]with the same intensity.

0:07:36.372,0:07:39.407
Let's take the cardiovascular[br]system, for example.

0:07:39.859,0:07:43.793
This area in medicine has done the most[br]to try to figure out

0:07:43.804,0:07:47.876
why it seems men and women have[br]completely different heart attacks.

0:07:48.906,0:07:52.483
Heart disease is the number one killer[br]for both men and women,

0:07:53.853,0:07:58.001
but more women die within the first year[br]of having a heart attack than men.

0:07:59.936,0:08:03.934
Men will complain[br]of crushing chest pain --

0:08:03.934,0:08:06.682
an elephant is sitting on their chest.

0:08:07.309,0:08:09.291
And we call this typical.

0:08:10.763,0:08:12.978
Women have chest pain, too.

0:08:13.682,0:08:19.902
But more women than men[br]will complain of "just not feeling right,"

0:08:21.446,0:08:24.270
"can't seem to get enough air in,"

0:08:24.889,0:08:26.907
"just so tired lately."

0:08:28.084,0:08:31.027
And for some reason we call this atypical,

0:08:31.027,0:08:35.082
even though, as I mentioned,[br]women do make up half the population.

0:08:36.268,0:08:41.852
And so what is some of the evidence[br]to help explain some of these differences?

0:08:42.927,0:08:44.906
If we look at the anatomy,

0:08:44.906,0:08:50.587
the blood vessels that surround the heart[br]are smaller in women compared to men,

0:08:51.648,0:08:55.354
and the way that those blood vessels[br]develop disease is different

0:08:56.120,0:08:58.357
in women compared to men.

0:08:58.823,0:09:02.907
And the test that we use to determine[br]if someone is at risk for a heart attack,

0:09:04.099,0:09:08.268
well, they were initially designed[br]and tested and perfected in men,

0:09:08.268,0:09:11.310
and so aren't as good[br]at determining that in women.

0:09:13.067,0:09:16.163
And then if we think[br]about the medications --

0:09:16.163,0:09:18.907
common medications[br]that we use, like aspirin.

0:09:20.661,0:09:25.151
We give aspirin to healthy men to help[br]prevent them from having a heart attack,

0:09:25.151,0:09:29.327
but do you know that if you[br]give aspirin to a healthy woman,

0:09:29.327,0:09:31.229
it's actually harmful?

0:09:33.373,0:09:35.935
What this is doing is merely telling us

0:09:35.935,0:09:38.505
that we are scratching the surface.

0:09:40.070,0:09:43.448
Emergency medicine[br]is a fast-paced business.

0:09:44.488,0:09:47.618
In how many life-saving areas of medicine,

0:09:47.618,0:09:49.789
like cancer and stroke,

0:09:51.929,0:09:56.057
are there important differences between[br]men and women that we could be utilizing?

0:09:57.585,0:10:02.012
Or even, why is it that some people[br]get those runny noses

0:10:02.012,0:10:03.830
more than others,

0:10:03.830,0:10:07.880
or why the pain medication that we give[br]to those stubbed toes

0:10:07.880,0:10:10.683
work in some and not in others?

0:10:14.411,0:10:18.962
The Institute of Medicine has said[br]every cell has a sex.

0:10:21.145,0:10:23.504
What does this mean?

0:10:23.915,0:10:25.718
Sex is DNA.

0:10:26.253,0:10:29.922
Gender is how someone[br]presents themselves in society.

0:10:31.346,0:10:33.795
And these two may not always match up,

0:10:33.795,0:10:37.181
as we can see with our[br]transgendered population.

0:10:38.056,0:10:41.864
But it's important to realize[br]that from the moment of conception,

0:10:43.063,0:10:45.246
every cell in our bodies --

0:10:45.246,0:10:48.584
skin, hair, heart and lungs --

0:10:48.584,0:10:51.263
contains our own unique DNA,

0:10:51.872,0:10:55.857
and that DNA contains[br]the chromosomes that determine

0:10:55.857,0:11:00.424
whether we become[br]male or female, man or woman.

0:11:01.638,0:11:03.388
It used to be thought

0:11:03.388,0:11:06.708
that those sex-determining[br]chromosomes pictured here --

0:11:07.923,0:11:11.087
XY if you're male, XX if you're female --

0:11:11.087,0:11:15.535
merely determined whether you[br]would be born with ovaries or testes,

0:11:16.424,0:11:19.673
and it was the sex hormones[br]that those organs produced

0:11:20.096,0:11:24.192
that were responsible for the differences[br]we see in the opposite sex.

0:11:26.345,0:11:29.967
But we now know that[br]that theory was wrong --

0:11:31.287,0:11:33.636
or it's at least a little incomplete.

0:11:33.636,0:11:37.760
And thankfully, scientists like Dr. Page[br]from the Whitehead Institute,

0:11:38.556,0:11:40.561
who works on the Y chromosome,

0:11:40.561,0:11:42.527
and Doctor Yang from UCLA,

0:11:42.527,0:11:48.015
they have found evidence that tells us[br]that those sex-determining chromosomes

0:11:48.015,0:11:50.754
that are in every cell in our bodies

0:11:50.754,0:11:55.299
continue to remain active[br]for our entire lives

0:11:58.005,0:12:01.644
and could be what's responsible[br]for the differences we see

0:12:01.644,0:12:03.810
in the dosing of drugs,

0:12:03.810,0:12:06.808
or why there are differences[br]between men and women

0:12:06.808,0:12:09.805
in the susceptibility[br]and severity of diseases.

0:12:12.450,0:12:15.291
This new knowledge is the game-changer,

0:12:18.881,0:12:22.023
and it's up to those scientists[br]that continue to find that evidence,

0:12:22.023,0:12:25.796
but it's up to the clinicians[br]to start translating this data

0:12:26.327,0:12:29.137
at the bedside, today.

0:12:30.692,0:12:32.318
Right now.

0:12:34.775,0:12:37.998
And to help do this, I'm a co-founder[br]of a national organization

0:12:37.998,0:12:40.955
called Sex and Gender[br]Women's Health Collaborative,

0:12:40.955,0:12:45.604
and we collect all of this data[br]so that it's available for teaching

0:12:45.604,0:12:47.170
and for patient care.

0:12:47.795,0:12:52.280
And we're working to bring together[br]the medical educators to the table.

0:12:53.234,0:12:55.280
That's a big job.

0:12:55.450,0:13:00.205
It's changing the way medical training[br]has been done since its inception.

0:13:02.676,0:13:05.080
But I believe in them.

0:13:05.445,0:13:09.817
I know they're going to see the value[br]of incorporating the gender lens

0:13:11.070,0:13:13.464
into the current curriculum.

0:13:14.260,0:13:18.283
It's about training the future[br]health care providers correctly.

0:13:21.873,0:13:23.053
And regionally,

0:13:23.053,0:13:26.803
I'm a co-creator of a division within[br]the Department of Emergency Medicine

0:13:26.803,0:13:28.423
here at Brown University,

0:13:28.423,0:13:31.434
called Sex and Gender[br]in Emergency Medicine,

0:13:31.434,0:13:35.969
and we conduct the research to determine[br]the differences between men and women

0:13:35.969,0:13:38.214
in emergent conditions,

0:13:38.214,0:13:43.046
like heart disease and stroke[br]and sepsis and substance abuse,

0:13:43.046,0:13:47.215
but we also believe[br]that education is paramount.

0:13:48.692,0:13:52.602
We've created a 360-degree[br]model of education.

0:13:52.602,0:13:57.499
We have programs for the doctors,[br]for the nurses, for the students

0:13:58.720,0:14:00.488
and for the patients.

0:14:01.000,0:14:04.598
Because this cannot just be left up[br]to the health care leaders.

0:14:06.012,0:14:09.153
We all have a role in making a difference.

0:14:12.311,0:14:15.818
But I must warn you: this is not easy.

0:14:18.287,0:14:20.162
In fact, it's hard.

0:14:21.416,0:14:24.966
It's essentially changing the way[br]we think about medicine

0:14:25.635,0:14:28.236
and health and research.

0:14:29.765,0:14:32.953
It's changing our relationship[br]to the health care system.

0:14:34.232,0:14:36.808
But there's no going back.

0:14:37.589,0:14:40.219
We now know just enough

0:14:41.442,0:14:43.547
to know that we weren't doing it right.

0:14:45.815,0:14:48.110
Martin Luther King, Jr. has said,

0:14:48.110,0:14:51.860
"Change does not roll in[br]on the wheels of inevitability,

0:14:52.570,0:14:55.079
but comes through continuous struggle."

0:14:56.650,0:14:59.481
And the first step[br]towards change is awareness.

0:15:00.350,0:15:04.535
This is not just about improving[br]medical care for women.

0:15:04.925,0:15:09.577
This is about personalized,[br]individualized health care for everyone.

0:15:11.177,0:15:16.812
This awareness has the power to transform[br]medical care for men and women.

0:15:18.950,0:15:23.850
And from now on, I want you[br]to ask your doctors

0:15:24.854,0:15:29.111
whether the treatments you are receiving[br]are specific to your sex and gender.

0:15:30.437,0:15:32.653
They may not know the answer --

0:15:33.342,0:15:34.680
yet.

0:15:35.278,0:15:39.194
But the conversation has begun,[br]and together we can all learn.

0:15:39.967,0:15:43.823
Remember, for me[br]and my colleagues in this field,

0:15:44.311,0:15:46.284
your sex and gender matter.

0:15:47.795,0:15:48.815
Thank you.

0:15:48.815,0:15:50.384
(Applause)